CARE HOMES FOR OLDER PEOPLE
Fieldway Residential Home 5 Fieldway Blythe Bridge Stoke on Trent Staffordshire ST11 9HL Lead Inspector
Sue Jordan Unannounced 4 May 2005 09:35 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Fieldway Residential Home Address 5 Fieldway Blythe Bridge Stoke on Trent Staffordshire ST11 9HL 01782 39355 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Thomas Hope Mrs Amanda Jane Hope Care Home 18 Category(ies) of 4 DE(E) registration, with number 18 OP of places 10 PD(E) Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 10 PD(E) - 1 may be age 60 on admission Date of last inspection 10/01/05 Brief Description of the Service: Fieldway is a residential care home for eighteen older people.The registered facility is all on the ground floor with sixteen single and one shared bedroom, all but one single room have en-suite facilities. There are two lounges and a smoking room/conservatory, as well as a separate dining room.Outside there is a lawn area for the use of the resident service users in good weather.The home is of modern construction and is furnished, decorated, and maintained to a high standard. There is a brick paved car park adjoining the front entrance, and the whole is situated in a quiet residential street with local services within half a mile, as is access to the bus route, with the railway station being about a mile away, close to the health centre. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours and the methodologies used were discussions with a new admission, other residents and two members of staff. As a consequence their records were also inspected. Lunch was shared with the residents, at which time the medication administration was also observed. The manager spent time explaining and demonstrating the most recent developments in the Home. What the service does well: What has improved since the last inspection?
Seventeen requirements were made as a result of the last inspection on 10/01/05 and thirteen have been successfully addressed. Of the remaining requirements work has taken place and major improvements made. Service user care plans have been re-organised and are now individually filed. The Home have undertaken their own assessments and as a result care plans have been developed, which contain clear concise instructions for staff on how
Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 6 to meet the residents’ needs. These improvements are to be further developed. The manager initiated a pharmacist visit to the Home, to check the medication systems and procedures. This is to be a regular event. Medication training is being identified for staff. At the last inspection a large number of staff had not had a Criminal Records Bureau check. At this inspection the Home was waiting for only two disclosures and the manager was able to demonstrate her knowledge of the Protection of Vulnerable Adults recruitment check. An application has been received by the Commission for Social Care Inspection to register the manager and this process is on going. The manager has spent time updating her knowledge of the required legislation and has attended vital training. She is presently training to be a manual handling trainer, which will mean that staff can be trained in techniques specific to the residents. The manager has started to develop a formal staff supervision system. Contact has been made with the Fire Safety Department and a simple risk assessment completed. External fire training is being planned. What they could do better:
Many of the improvements in the Home are ongoing and the manager is aware that they require further development. The Home must firstly ensure that the Statement of Purpose is an accurate reflection of the Home and that the promises within it are achievable and can be kept. Assessments must be undertaken of all potential service users to ensure that the Home is able to meet their needs. Changing needs must be identified within the care plans and reviewed regularly. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 7 Choices are available to the residents throughout their daily lives, however this could be extended and thought should be given as to how this can be achieved. The manager must ensure that she has an up to date copy of the Local Authorities Adult Protection Procedures and then arrange for all staff to be trained as to what to do in the event of an abusive situation. Although there have been improvements in the recruitment procedures the manager must ensure that appropriate references are obtained for all new staff. Training has been attended and planned for the manager and staff, however it is difficult to monitor whether the staff are receiving mandatory training at the required frequencies. A staff supervision system has been implemented, although the manager is unsure as to how to proceed further. It is recommended that she attend training in staff supervision and appraisal. Quality questionnaires are available, but there is no evidence that they have been given to the residents, their families or others involved in the Home. The management can review the results of the questionnaires and use them to monitor the progress and care in the Home and make improvements if necessary. An evaluation of the answers given should be added to The Service Users’ Guide, so that potential and existing service users and their families know the general views and that action is taken to improve services if required. These quality audits should be done on a regular basis and it is suggested that this be at least annually. Generic and Health and Safety risk assessments were completed in the past but the new manager needs to review them and check that they are still applicable to the Home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, Although assessments and care plans are completed by the staff very soon after a service user moves into the Home, a lack of pre-admission information could result in vital needs not being met. The Statement of Purpose and Service Users’ Guide are not an accurate reflection of the Home. Therefore they do not enable prospective service users, their families and the professionals making referrals to make an informed choice as to whether they wish to live in the Home. EVIDENCE: The Statement of Purpose has been updated and a copy given to the CSCI, (Commission of Social Care Inspection), however this document does not contain all of the required information and the manager’s attention is drawn to Schedule 1 of The Care Homes Regulations, which lists the information needed. An ‘Admissions Pack’ has also been developed, which it is assumed is intended to serve as a Service Users’ Guide. However, again this does not include all of
Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 10 the required elements. The manager reported that she is still working on these documents. The records of the most recent admission were checked during this inspection. The Home has made a good effort to develop his care plans, however there is a lack of pre-admission information. The care plan received by the Local Authority refers to home care services and not residential care. The service user initially entered the Home for respite care and has since become permanent. This situation was planned and reviewed with the resident, his family and social worker. The manager said that the lack of pre-assessment information was due to this service user being admitted in an emergency. This has created some problems for the Home as they are still discovering important issues some three months later, one of which could have been potentially very dangerous to the resident. The manager has contacted the social worker for more information. The management of the Home must decide whether they are able to accept emergency admissions and are advised to adhere to their promises in The Statement of Purpose, which states that the manager will visit the prospective service user in their own home or hospital. The senior staff at the Home have undertaken their own assessments for the resident and these include mobility, manual handling, activities and the likelihood of pressure sores. The manager is to introduce a new manual handing assessment tool, which will contain a risk assessment and instructions to staff. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11 Major improvements have been made to care planning. This should be further developed to include regular review, thereby ensuring that the residents receive the care required to meet their changing needs. EVIDENCE: Each resident now has their own file and the records contain clear information for staff. The senior staff are responsible for completing the care plans and are to be commended for their efforts. They are encouraged to develop this further and ensure that the care plans are regularly reviewed and amendments made as and when required. For example, it was observed during this visit that one of the residents is now given a sugar substitute. A staff member gave a reasonable explanation and suggested that the general practitioner had been involved in this decision. On checking the care plan, there was no mention of this change and the reasons why. The records continue to explain that the resident likes to have three spoons of sugar. Another resident has a nut allergy, however there is not enough information as to how severe this is and the precautions to be taken. The manager is however trying to gather this information.
Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 12 A number of mobility assessments are being used and it was agreed that a new format found by the manager will streamline the information and also include the vital risk assessment. The Home has introduced some good forms into the care plans, for instance family involvement, wishes in the event of illness, death and dying and the use of a bedroom door key, which are yet to be completed. Records are now being kept of all medical and health professional visits and appointments and this provides evidence that health services are being obtained for the residents. These include, general practitioners and opticians. The manager has made contact with a chiropodist. The Home must ensure however that health decisions are backed by the appropriate professional, for instance in the case of the sugar substitute mentioned previously and that this is recorded. The residents are being weighed regularly and personal medical histories and medication records are completed. The medication records and procedures were checked. The deputy manager was observed administering the lunchtime medication and she demonstrated her knowledge of the correct procedures to follow. A pharmacist monitored the Home’s systems in January 2005 and is due to return in May. The manager has obtained training booklets for medication and is going to check their suitability with the pharmacist. She has also made attempts to access the ‘Safe Handling of Medicines’ training for staff. During this inspection, visitors spent time with one of the residents in his bedroom. He confirmed that staff had eased his embarrassment in receiving personal care. He also said that he was able to go to bed and get up when he wished. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Regular activities are organised for the residents and they choose whether they want to be involved. Plans are being made to offer more choices to the residents, which will give them further control over their lives. EVIDENCE: The Home employs an activities co-ordinator, although she was not working on the day of this inspection. She had however developed a plan to be continued in her absence. Some of the residents confirmed that they continued to enjoy the activities provided, whilst another stated that he did not want to get involved. A resident said that his family had been made very welcome by the staff and another visitor was introduced to the Home and the manager during this inspection. Two members of staff said that the residents received many visitors and the Home had been particularly busy over the previous bank holiday weekend. Personal preferences for daily routines are being recorded in the care plans and a resident confirmed that he was able to get up and go to bed when he chose and that he liked to spend some time alone in his room, which is respected. One of the residents said that she thought that they would use the garden in the warmer weather. Lunch was shared with the residents and they did not know what they were having for lunch, because the menu board had not been completed. It was noted however that an alternative was quickly
Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 14 provided for one of the residents. The manager said that she is hoping to introduce a choice of main course, which can be chosen the day before. The cook and a care worker have been given the responsibility of seeking residents’ likes and dislikes and developing a new menu. All of the residents asked said that the food provided in the Home is good and that they enjoy it. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The approachability of the manager and staff allow the residents the confidence needed to express their concerns. The appropriate checks are now being made for potential staff members, however some deficiencies in the Home’s recruitment procedures and the lack of Adult Protection training do not fully protect the service users. EVIDENCE: There have been no complaints made to the Home, but the manager has prepared a book for recording them, should the need arise. One of the residents said that he knew who to approach if he had any concerns and that he would feel comfortable doing so. A requirement was made at the last inspection that CRB, (Criminal Records Bureau), disclosures be obtained for all staff. This was checked at this inspection and all but two have been received. A POVA, (Protection of Vulnerable Adults), check was made for a new member of staff. However, written references had not been received prior to employment and a verbal, telephone reference had not been recorded. The multi-disciplinary Adult Protection procedure was found at this inspection. It is dated 2001 and the manager agreed to contact the Local Authority Adult Protection team to check that it is current. Training in the correct procedures to follow in the event of an abusive situation must then be arranged. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 24, 26 The Home is well maintained and provides a clean, safe environment for the residents. EVIDENCE: The Home provides a comfortable and clean environment for its residents. Each of the outside doors has a buzzer attached, which notifies the staff of any exit from the Home. A new bath chair has been purchased and the hoists have been serviced. There are ample communal facilities, allowing the residents a choice as to where they spend their time. The conservatory is the designated smoking area. Most of the residents have their own bedroom and they are currently being formally offered the opportunity to have a key. One of the new residents said that his family are going to bring some of his personal possessions for his room. This is encouraged by the Home. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 17 The staff said that the new manager has heightened Health and Safety awareness in the Home. There has been an Environmental Health visit to the Home and the manager has received and completed a fire safety risk assessment from the Fire Safety Department. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The Home has a consistent, friendly staff team, however although there have been major improvements since the last inspection, the recruitment and training practices must be strengthened to provide protection to the residents. EVIDENCE: On the day of this inspection, there were two senior care workers, the manager, a domestic and a cook on duty. The staff reported that there are normally three care workers on duty allowing the manager time to concentrate on her managerial role. The present gap in the staff team has recently been filled and a member of staff on maternity leave is due to return soon. This will bring the staff team up to its full complement. The staff team are generally very consistent and many have worked at the Home for a number of years. Four staff recruitment files were checked and major improvements were noted. The manager has started to gather all of the required information for existing staff and photos are being attached. A requirement was made at the last inspection that CRB, (Criminal Records Bureau), disclosures be obtained for all staff. This was checked at this inspection and all but two have been received. A POVA, (Protection of Vulnerable Adults), check was made for a new member of staff. However, written references had not been received prior to employment and a verbal, telephone reference had not been recorded. The absence of an application form was also noted and the manager reported their unavailability. She also said that there are no reference request forms. This must be addressed. New contracts for staff are now ready to go out to the staff. The
Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 19 manager agreed to obtain copies of the General Social Care Council code of conduct and give them to all staff. Staff are given copies of the Home’s relevant policies and procedures and sign for them on receipt. The day before the inspection, the manager and deputy had attended training in dementia and challenging behaviour, medicines, diabetes and law and abuse. The manager is presently training to be a manual handling trainer and the staff are waiting for her to finish this award. The staff spoken to were enthusiastic to receive training and the manager demonstrated a commitment to this. She is aware that at present the training is not fully up to date and is in the process of collating the information needed. It was recommended that a matrix be developed, which will enable closer monitoring and provide evidence at inspections that staff receive mandatory training and the required refreshers. More knowledge is needed of what training must be provided, including induction and foundation and the manager was given some guidance at this inspection. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37, 38 The manager has worked hard to address the concerns raised at the last inspection, familiarising herself with the relevant legislation and improving the record keeping in the Home. The manager is committed to improvement, which can only further benefit the residents and the staff. EVIDENCE: The manager Hazel Malbon has been in post since January 2005 and she has worked hard to address the requirements made as a result of the last inspection. An application of registration has been sent to the Commission for Social Care Inspection and this is presently being processed. The staff confirmed the improvements implemented by the manager and also said that teamwork and communication between the staff has improved. They also said that the manager encourages and motivates the staff. A resident said that he thought that the manager was good and approachable.
Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 21 The manager is currently undertaking NVQ 4 in care and management and she has recently attended additional training, pertinent to the needs of the residents. She has obtained a copy of the National Minimum Standards and now has a job description, although this was considered rather vague. A quality assurance system is still to be developed in the Home, which should include the views of service users, their friends and family and stakeholders in the community, including for example GP’s. The results of the service user surveys must collated and added into the Service User’s Guide. The manager has started a system of formal supervision for staff and this has taken the form of staff meetings and individual observations. It is recommended that the manager receive training in staff supervision to enable her to conduct supervision more effectively. Record keeping in the Home has greatly improved since the last inspection and the manager and staff team are to be congratulated. The manager has contacted the Fire Safety Department and as a result has received and completed a simple fire risk assessment. She has also received new fire logbooks and is planning fire training with a professional, external organisation. Health and Safety meetings are being planned with the staff. Accidents and incidents are well recorded and the manager analyses these regularly. It was not possible to check all of the Health and Safety records, as they were not available for the required maintenance checks in the Home. The proprietor is asked to make them available for the announced inspection. It was noted that the PAT, (portable appliance testing), is due in the Home. Generic risk assessments have been undertaken in the past by the previous manager. However these have not been reviewed and require re-visiting so that the present manager can either endorse or amend them. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 2 x x 2 x 2 Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4, 5, 6 Requirement The Statement of Purpose and Service Users’ Guide must be updated to reflect the current service provided at the Home. These documents must be reviewed and amended as necessary. Previous Requirement. New service users must only be admitted following a full assessment. The care plans must be regularly reviewed and amended to meet the changing needs of the residents. Decisions made on behalf of the residents with regard to their health must be based on the advice of medical professionals and recorded as such. Personal wishes regarding death and dying should be ascertained and included in the care plans. Staff must know the local procedures to follow in the event of an abusive situation. This should be addressed by ensuring the Home has access to the current Local Authority Adult Protection Procedures and that staff are suitably trained. Timescale for action 01/06/05 & on-going 2. 3. 3 7 14 15 (2b) 01/06/05 & on-going 01/06/05/ & on-going 01/06/05 & on-going 4. 8 13 (1b), 12 (1, 2, 3) 12 (1, 2, 3) 13 (6) 5. 6. 11 18 01/08/05 & on-going 01/07/05 & on-going Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 24 7. 29 17, 19, Schedule 2 8. 30 18 (1ci) 9. 33 24 10. 11. 36 38 18 (2) 13 (4), 23 (2b) 12. 38 13 (4) All staff personnel files must contain all of the required elements listed in Schedule 2 of The Care Homes Regulations. Previous Requirement. Staff should be given copies of the GSCC code of conduct. More evidence is required that all staff have received mandatory training at the appropriate frequencies. Previous Requirement. A Quality Assurance system must be developed, which includes ascertaining the views of the service users, their friends and family and stakeholders in the community, including for example GP’s, chiropodist etc. The results of the service user surveys must collated and added into the Service User’s Guide. Previous Requirement The staff supervision should be further developed to include the elements listed in 36.3. More evidence is required that Health and Safety in the Home is maintained by the appropriate checks, made by professional personnel. The generic risk assessments must be reviewed. 01/06/05 & on-going 01/07/05 & on-going 01/07/05 01/06/05 & on-going 01/06/05 & on-going 01/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 1 3 Good Practice Recommendations It is recommended that a date be added to The Statement of Purpose and Service User Guide at each review and/or amendment. The Home should consider whether it is feasible to accept emergency admissions. This decision must be included in
E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 25 Fieldway Residential Home 3. 4. 7 30 5. 36 The Statment of Purpose and adhered to. It is recommended that the residents and/or families be asked to sign the care plans. It is recommended that the manager develop a matrix, which will provide the evidence needed that all staff receive mandatory training at the appropriate frequencies and assist the monitoring of training needs. It is recommended that the manager and deputy share staff supervision responsibilities and as such receive training in staff supervision and appraisal. Fieldway Residential Home E51-E09 S4943 Fieldway V227172 040505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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